200 Years of Florence and the challenges of nursing practices management in the COVID-19 pandemic*

Objective to analyze the main challenges of nursing in facing Coronavirus Disease-19 under the perspective of nurse managers in the west macro-region of Santa Catarina. Method it consists of a qualitative study, whose data collection was done through interviews with nurses who represent the management of health care network in the region. The analysis technique used was the Discourse of the Collective Subject (DCS). Results the legacy of Florence Nightingale to contemporary nursing practice; the weaknesses and the technical operational capacity with which nursing faces in the Unified Health System (Sistema Único de Saúde - SUS); the strategies for strengthening the Unified Health System and qualification of nursing practices; and the potentialities identified in the pandemic scenario were the main ideas that emerged. In the bicentennial year of Florence Nightingale, nurses recognize her legacy to public health practice and management. Several variables interfere in professional practice, such as epidemiological aspects, working conditions, and care management in a pandemic. Conclusion the pandemic scenario has taken nursing to a position of practical and scientific protagonism as a result of its proactivity and leadership in the search for knowledge based on scientific evidence.

The legacy of Florence directed the work of the nurse professional to a performance based on technicalscientific, legal, and political protagonism. This is only possible using practices committed to social well-being in the dimensions of care, management, and research/ education. The care and management of nursing requires theoretical support and scientific evidence.
Thus, the research contributes to the safety in the performance of the practices, without disregarding the subjective dimension involved in the act of caring and/ or managing (4) .
Currently, the incorporation of clinical evidence to guide the practice mediated by technologies such as protocols and guidelines, even with timid regulation in Brazil, was responsible for greater visibility and autonomy of nursing and, at the same time, created challenges for the nurse in the Health Care Network (HCN). These challenges are due to the lack of training for the most complex skills, which involve requesting tests and prescribing medications, as well as evidencebased practice (1) .
In the midst of the historical context and challenges faced by the professional nurse, in December 2019, after cases reported in the city of Wuhan, China, a new virus from the coronavirus family was discovered. Named as Severe Acute Respiratory Syndrome (SARS-Cov-2), it is responsible for COVID- 19. The disease has become a serious public health problem worldwide, evolving very quickly and depleting the responsiveness of health systems.

COVID-19 causes respiratory infections, presenting
symptoms that vary in intensity (mild, moderate, or severe) and that are usually intensified by comorbidities presented by individuals. In some cases, the disease may manifest itself in a severe and high lethality (5) .
At the beginning of 2020, with the disease widespread in several continents, the World Health Organization (WHO) determined the situation of a pandemic. In Brazil, the condition worsens daily with an ascending characteristic and growth in the epidemic curve, which began on March 2, with two confirmed autochthonous cases. On May 5, 2020, cases totalized 114,715 (5) . SARS-Cov-2 has been presenting a pattern of high transmissibility in some geographic areas of Brazil. This fast growth has increased the suspected cases, without the necessary notification of confirmation, implying a probable Brazilian undersized epidemic curve, which weakens the strategies to contain the pandemic (6)(7) .
The estimated death rate among patients treated clinically until May 26, 2020, was approximately 2% of the cases, but the actual number remains unknown, given the underreporting and deaths attributed to other causes due to poor testing. On May 5, 2020, in Brazil, lethality was 6.9% (5) , of which the elderly population and those with chronic conditions represent the main risk groups (8-9) .
The changes caused by COVID-19 have led to interventions that alter people's daily lives significantly and put health workers at risk. By acting in the front line, in this context, the nursing team has dealt more frequently with records of contamination, illnesses, deaths, suicides, anxiety and panic crises, as well as the worsening of other diseases, which have been increasingly frequent (10) .
Based on these events, the debates that involve the capacity of healthcare services are amplified. Among the key points is the availability of health professionals.
Thus, the preservation of the physical and mental health of health workers, which pervades working conditions in the care of victims of COVID-19, is essential for adequate care practices, as well as for the maintenance of the available labor force.
Likewise other historical times when epidemics and disasters have affected populations, nurses have put themselves at risk to provide health care.
for educational and prevention actions for the general population at risk of illness.
The nurses in the west of Santa Catarina stand out for their strong adherence to hospital services and to Primary Health Care (PHC) and, more recently, for their work in undergraduate and graduate teaching. Based on a path marked by pioneering, nurses "have been promoting changes in nursing practice and teaching, provoking transformations and influencing the culture of nursing care in the region" in different contexts (16) .
From a historical perspective, the present study is justified by the debate, since Florence Nightingale, whose bicentenary is celebrated in 2020, the role and contributions of the practices developed by nursing under the perspective of nurses who are in charge of the pandemic in the management of different services and coping with major health emergencies.
It is intended to signalize the main challenges in the action against COVID-19. In order to do so, we

Method
Analytical study of a qualitative approach that is part of the multicentric research project entitled "Nursing care and management as knowledge in the field of primary care: proposals for good practices", approved by the Research Ethics Committee, under record No. pandemic, potential participants were initially consulted through the WhatsApp messaging application.
After the first contact, an email was sent with a link to access a Google Forms form, which contained in its initial structure the acceptance of the Free and Informed Consent Form (FICF), followed by the interview questions.
From the date the forms were sent by e-mail, seven working days were waited for the forms responses.
During the period, the project team made up to two contacts with the participants to remind them of the remaining time to answer the questions sent. The information was produced in April 2020. To obtain the data in order to ensure the quality and reliability of the study, the principles of the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed.
The data were organized and analyzed manually, using the Discourse of the Collective Subject (DCS) technique. In this proposal, we sought to extract from the interviews: 1) Key Expressions (KE), consisting of literal excerpts or transcriptions of the discourse that reveal the essence of the discursive content; 2) Central Ideas (CI), which are statements that translate the essence of the discourse in order to briefly describe its meaning. CI can be redeemed by direct or indirect/ mediate descriptions of the meaning of the statement that reveal the subject of the statement (17)(18) .
The analysis followed the following steps: (1) exhaustive reading of each interview transcript; (2) identification of themes and grouping of KE; (3) identification of major themes; (4) identification and grouping of KE by theme; (5) identification of the CI in each theme; (6) elaboration of the DCS; (7) analysis of the set of DCS in each theme (17)(18) .
Representative CI emerged from the challenges mentioned by nurse managers, which were organized as shown in Figure    The CI identified in the data were discussed based on scientific literature in order to articulate the theoretical aspects that influence illness since Florence to the nursing professional practices in the context of pandemic.

The first CI, which regards the Legacy of Florence
Nightingale for the practice of nursing, highlights the importance of hygiene practices over two hundred years.  (20) . From the legacy of the precursor of nursing, the knowledge brought to daily life, such as those with the environment and the washing of the hands, became scientifically grounded. and finally, detecting and quarantining suspected and confirmed cases (3,9) .
Nightingale's environmental theory provided nursing with a new discipline based on its own body of knowledge mediated, giving the nursing professional support and authority to act freely. By consolidating partnerships to defend the autonomy of nurses, as well as its freedom to act and think during professional activity, the need for a training centered on the assumptions of nursing science has emerged (20) .
In In addition, the International Council of Nurses, the

WHO, and the UK All Party Parliamentary Group on Global
Health launched the Nursing Now Campaign in 2018, which will be completed in 2020. This campaign has the participation of more than 30 countries, including Brazil.
Nursing constitutes half of the health workforce, and nurses are appointed as the main responsible for coordinating health teams at different levels of care.
One of the strategies for investing in the workforce and valuing nurses for the advancement of the profession is the articulation between educational institutions and health services (21) . In addition to encouraging the use of research to ensure better nursing practices, the approximation of professionals to real health production scenarios allows the recognition of the potentialities and weaknesses of the system, as well as the needs users have, making them protagonists in this production (27) .
Nursing has shown the dimension of its importance in combating COVID-19. Even with the lack of professionals to act in the face of the pandemic and with a context of confrontation, which has at times cost these professionals their lives, the time is ripe for Brazilian nursing to leverage their visibility, demonstrating competence in the face of the current scenario. Rev. Latino-Am. Enfermagem 2020;28:e3358.
However, the deficit in quality training makes it necessary to adopt strategies that help at work. The support of permanent education, combined with the use of protocols and evidence-based practice, contributes to developing resilience in the nursing workforce (30) and to the profession's autonomy. It should also be noted that such autonomy is based on the use and incorporation of the nursing process, and in line with its theoretical roots.
The professional nurse needs to seize the methods, processes, and technologies that promote different human functions. It is also advisable to debate and reflect on the training of personnel in order to break with a model that focuses on compliance with hospital prescriptions and routines. It is time for nurses to be valued as a critical, reflective, and autonomous profession (20) .
In developed countries, such as England, Spain, the United States, Canada, and Australia, nursing works by developing advanced nursing practices in numerous contexts, but mainly in PHC (31)(32)(33) . With different levels of autonomy between the mentioned countries, an advanced practice nurse accompanies patients with chronic conditions through the management and handling of cases, including ordering tests and prescribing medications. This practice is guided by care protocols and is supported by the laws of those countries (33) .
In times of a pandemic, such as that of COVID-19, clinical nursing care based on knowledge and autonomy (29) reinforces the forefront of health professionals for the care of at-risk groups, which includes people with chronic conditions and the elderly. In this regard, Brazil needs to advance in the discussion about the implementation of advanced nursing practices so that the principles and guidelines that guide SUS are made effective, especially in PHC (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29) .
As presented in the fourth CI, which portrays the Macro and micropolitics determine the health model and way of acting in nursing, as they shape nurses' practice and workplaces at the local, regional, national, and international levels. In this scenario, nurses commonly act as policy implementers, but they rarely play a central role in their development, assuming a leadership role in the areas of health and social policy (36-37) .
In short, it was observed in the discourse of the nurse managers a concern with working conditions in the face of the pandemic and the SUS situation. Despite In the year that Florence Nightingale's bicentenary is celebrated, nurses recognize her legacy and consider it for their public health practices and management.
However, it is necessary to move forward in the field of scientific knowledge regarding the performance in pandemic scenarios, understanding the adversities of the profession and its multi and interprofessional relationships in times of crisis in public health.
This historic moment of the pandemic will mark public health as a result of the transformations caused by a virus that has spread rapidly throughout the world.
The current scenario has valued nursing for its role in the construction of its body of knowledge, in the proactive organization of care and the SUS, in its leadership capacity, and in the development of knowledge and skills based on scientific evidence, with emerging trends after Coronavirus Disease-19.